Of proxies and POLSTs: The good and the bad in end-of-life planning

Fr. Tadeusz Pacholczyk

Planning for end-of-life situations is important. We should put in place an advance directive before our health takes a serious turn for the worse and we are no longer able to indicate our own wishes or make our own decisions. Advance directives can be of two types: living wills and health care agents.

The best approach is to choose a health care agent (a.k.a. a “proxy” or a “durable power of attorney for health care”). Our agent then makes decisions on our behalf when we become incapacitated. We should designate in writing who our health care proxy will be. The National Catholic Bioethics Center (www.ncbcenter.org) and many individual state Catholic conferences offer helpful forms that can be used to designate our proxy. Copies of our completed health care proxy designation forms should be shared with our proxy, our doctors, nurse practitioners, hospice personnel, family members and other relevant parties.

In addition to choosing a health care proxy, some individuals may also decide to write up a living will in which they state their wishes regarding end-of-life care. Living wills raise concerns, however, because these documents attempt to describe our wishes about various medical situations before those situations actually arise, and may end up limiting choices in unreasonable ways. Given the breathtaking pace of medical advances, a person’s decisions today about what care to receive or refuse may not make sense at a later timepoint. In the final analysis, it is impossible and unrealistic to try to cover every medical situation in a living will, and it is preferable to have a proxy, a person we trust, who can interact with the hospital and the health care team, weigh options in real time, and make appropriate decisions for us as we need it.

A new type of living will known as a “POLST” form — a tool for advance planning — also raises concerns. The POLST form (which stands for Physician Orders for Life Sustaining Treatment) is a document that establishes actionable medical orders for a patient’s healthcare. The form is typically filled out with the help of trained “facilitators” — usually not physicians — who ask questions about patients’ health care wishes, and check boxes on the form that correspond to their answers. The facilitators receive training that can lead them to paint a rather biased picture of treatment options for patients, emphasizing potential negative side effects while side-stepping potential benefits or positive outcomes.

POLST forms thus raise several significant moral concerns:

1. The approach encouraged by the use of POLST forms may end up skewed toward options of non-treatment and may encourage premature withdrawal of treatments from patients who can still benefit from them.

2. Filling out a POLST form may preclude a proxy from exercising his or her power to protect the rights of the patient, since the form sets in motion actual medical orders that a medical professional must follow. As a set of standing medical orders, the POLST approach is inflexible. Many POLST forms begin with language like this: “First follow these orders, then contact physician or health care provider.” Straightforwardly following orders created outside of a particular situation may be ill-advised, improper and even harmful to the patient.

3. In some states, the signature of the patient (or his or her proxy) is not required on the POLST. After the form has been filled out, it is typically forwarded to a physician (or in some states to a nurse practitioner or a physician’s assistant) who is expected to sign the form. Thus, in some states, a POLST form could conceivably be placed into a patient’s medical record without the patient’s knowledge or informed consent. In a recent article about POLST forms in the Journal of Palliative Medicine, approximately 95 percent of the POLST forms sampled from Wisconsin were not signed by patients or by their surrogates. Fortunately, in some other states like Louisiana, the patient’s signature or the signature of the proxy is mandatory for the form to go into effect.

The implementation of a POLST form can thus be used to manipulate patients when they are sick and vulnerable, and can even lead to mandated orders for non-treatment in a way that constitutes euthanasia. The POLST template represents a fundamentally flawed approach to end-of-life planning, relying at its core on potentially inappropriate medical orders and dubious approaches to obtaining patient consent.

Notwithstanding the pressure that may be brought to bear on a patient, no one is required to agree to the implementation of a POLST form. Patients are free to decline to answer POLST questions from a facilitator, and should not hesitate to let it be known that they instead plan to rely on their proxy for end-of-life decision making, and intend to discuss their healthcare options uniquely with their attending physician.

 

COMING UP: Catholic Charities joins with St. Raphael Counseling to increase services

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Two Catholic counseling agencies serving the Denver Archdiocese have united to expand services to the community, officials said. The change was effective May 1.

St. Raphael Counseling, founded in 2009, has partnered with Catholic Charities’ Sacred Heart Counseling (formerly Regina Caeli Clinical Services), which was established in 2011. The two are now one ministry under Catholic Charities of Denver sharing the name St. Raphael Counseling.

Licensed clinical psychologist Jim Langley, co-founder of St. Raphael’s, will serve as director.

“Frankly, it seemed kind of silly for two entities to be doing the same thing from the same pool of resources,” Langley told the Denver Catholic.  “I reached out to [Catholic Charities] … to see about removing obstacles. It really must have been from the Lord because there weren’t any big obstacles.”

The combined resources mean clients seeking care aligned with Catholic values will now have access to more therapists and locations: a total of 18 clinicians at 11 offices and six schools across the Front Range region, including Denver, Littleton and northern Colorado.

In the coming months, St. Raphael’s will accept more insurances and will introduce diagnostic testing for behavioral and learning disorders and Autism to families at affordable cost, Langley said.

“We are excited to welcome the team of psychologists from St. Raphael Counseling to Catholic Charities,” said Amparo García, interim president and CEO of Catholic Charities of Denver. “Under Dr. Langley’s guidance, and with his expertise and business acumen, the team has built a trusted and professional counseling service that is faithful to the Church and compassionate to those in need.

“We are optimistic that offering expanded services in a combined organization will provide an added benefit to the community.”

St. Raphael’s offers individuals, couples and families clinical counseling services for issues ranging from depression and anxiety to grief and addiction. It also offers marriage preparation, school counseling, psychological evaluations for seminary applicants, and counseling for priests and religious. It provides outreach and education through presentations and retreats that integrate psychology and spirituality.

St. Raphael’s is named after the Archangel Raphael, who in the Old Testament Book of Tobit is sent by God to help the young man Tobias confront nature and evil. Raphael helps to bring healing to Tobias’ family. Of Hebrew origin, Raphael means “God heals.”

“The name was chosen very deliberately,” Langley said. “We [as therapists] are only instruments of God’s healing, God’s medicine; it’s ultimately God who heals.

“One of the ways the Lord has given us as a path to holiness is through our own brokenness,” he added. “We all have emotional wounds and the healing of these wounds helps us to become the saints God made us to be.

“We work with individuals and families to help them face their woundedness, their brokenness. We do it in a way that is supportive of their Catholic values and can leverage all the awesome, beautiful things about Catholic spirituality that can help us grow as people.”

The recent suicides of celebrity chef Anthony Bourdain and fashion designer Kate Spade show that no one is immune from depression and suicidal thoughts, Langley said.

“Even St. Therese [of Lisieux] said there were moments when she was tempted by the medicine bottle on the nightstand,” he noted about the saint who was named a Doctor of the Church in 1997. “We think of her as being a joyful saint, yet she too struggled immensely with depression.

“If people are struggling, they need help,” Langley said. “But counseling isn’t just for people with big issues. It’s also for those who have normal issues and are trying to have a healthy family life.

“There’s nobody who doesn’t need support and good human relationships.”

RAPHAEL COUNSELING

Visit: straphaelcounseling.com

Phone: 720-377-1359